V 


THE  MODERN  UNIVERSITY  SCHOOL— ITS 
PURPOSES  AND  METHODS.* 


JOHN  M.  DODSON,  M.D. 

CHICAGO. 


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The  earliest  American  medical  schools  were  estab- 
lished in  connection  with  institutions  of  general  learn- 
ing, as  would  have  been  expected  from  the  fact  that  the 
physicians  who  founded  them  had  been  educated  in 
Great  Britain  and  France,  where  the  medical  colleges 
were,  without  exception,  departments  of  universities. 
Only  a few  of  the  American  schools,  however,  were  es- 
tablished with  such  a relation,  the  larger  majority  be- 
ing quite  independent  of  any  university  or  college  con- 
nection, so  that  in  1877,  twenty-five  years  ago,  less  than 
twenty  of  the  sixty-five  medical  colleges  then  in  exist- 
ence were  connected  in  any  way  with  institutions  of  gen- 
eral learning.  Subsequent  to  that  date,  however,  such 
schools  have  become  much  more  numerous,  and  of 
the  one  hundred  and  fifty-eight  medical  schools  at 
present  existing  in  America,  between  sixty  and  seventy 
are  connected  with  a university  or  college. 

These  facts  suggest  some  interesting  queries.  Why 
were  not  all  of  our  medical  schools,  following  the  ex- 
ample of  those  first  founded,  established  in  connection 
with  institutions  of  general  learning  ? What  motives  have 
prompted  the  movement  which,  starting  about  1880,  lias 
resulted  in  the  large  increase  in  medical  schools  so  con- 
nected? What  is  the  nature  of  the  relationship  which 
exists  to-day  between  the  medical  schools  and  the  uni- 
versities with  which  they  are  connected  ? Has  this  re- 


* Read  at  the  Annual  Meeting  of  the  Washington  State  Medical 
Society.  Tacoma,  Wash.,  June  2C>.  1902. 

p 10592 


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lationship  resulted  in  the  largest  possible  measure  of 
advantage  to  either  the  medical  school  or  the  university  ? 
And  finally,  what  should  be  the  nature  of  this  relation- 
ship in  order  that  the  best  results  may  be  secured  ? 

THE  DIFFERENT  CONDITIONS  IN  THE  EARLY  DAYS. 

In  answer  to  the  first  query  it  may  be  noted'  that  there 
were  no  universities  in  America  in  the  broad,  European 
sense  until  comparatively  recent  years.  Our  institu- 
tions of  higher  learning  were,  as  most  of  them  still  re- 
main, colleges,  devoted  to  purely  academic  instruction, 
in  the  classics,  mathematics  and  philosophy.  Such  an 
institution  has  nothing  in  common  with  the  professional 
school,  and  there  can  be  little  advantage  or  propriety 
in  any  connection  between  them.  Then,  too,  it  was 
hardly  possible  to  establish  the  medical  school  on  such 
a basis  as  to  make  it  a fit  member  of  a university  organ- 
ization. The  rapidly-growing  country  demanded  phy- 
sicians in  large  numbers,  trained  as  best  they  might  be 
for  practical  life,  but  with  requirements  and  the  ex- 
pense of  the  college  course  such  as  not  to  place  it  beyond 
the  reach  of  all  but  a few  students.  Until  the  middle 
of  the  last  century  the  majority  of  students  entered  the 
practice  of  medicine  through  an  apprenticeship  with  a 
preceptor.  The  chief  problem  was  how  to  induce  these 
students  to  spend  any  time  at  all  in  the  medical  school, 
and  to  have  exacted  high  requirements  for  admission, 
and  a prolonged  and  expensive  course  would  have  been 
to  defeat  the  very  purpose  for  which  the  school*  was  es- 
tablished. But  a college  with  such  standards,  little  or 
no  restriction  as  to  preliminary  education,  graduating 
after  attendance  on  two,  four  or  five  months’  sessions 
of  repetitional  lecture  courses,  could  not  fittingly  have 
been  made  a department  of  a true  university. 

Thus  medical  colleges  came  to  be  established  by  med- 
ical men  as  independent  institutions,  sometimes,  it  is 
true,  with  other  than  the  highest  motives,  but,  on  the 
whole,  with  an  honest  purpose  to  meet  a real  need.  In 
passing  judgment  on  these  colleges  and  their  founders 
due  regard  must  be  taken  of  the  conditions  which  ob- 
tained at  the  time  they  were  organized.  In  the  absence 
of  endowment  or  financial  aid  from  the  state  the  college 
had  no  resources  excepting  from  the  fees  of  students, 
which  were  of  necessity  low.  It  was  imperative  that 


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the  standards  of  the  school  should  be  such  as  to  insure 
a sufficient  number  of  students  to  maintain  it  on  a work- 
ing basis.  For  the  past  twenty-five  years  there  has  been 
no  real  demand  for  more  medical  colleges,  and  the  judg- 
ment if  not  the  motives  of  those  who  have 
instituted  most  of  the  colleges  established  within 
this  period  may  well  be  questioned,  but  previous 
to  that  time  the  physicians  who  established  the 
medical  colleges  of  the  old  type  were,  with  few  excep- 
tions, animated  by  an  honest  purpose,  and  possessed  a 
logical  and  discriminating  judgment  in  adjusting  the 
standards  of  education  very  closely  to  the  needs  and 
conditions  of  the  times.  These  institutions,  sometimes 
styled  commercial,  never,  so  far  as  I have  knowledge, 
yielded  a direct  money  profit,  though  the  indirect  return 
to  the  occupants  of  the  clinical  chairs  was  in  many  cases 
large.  Fortunately,  the  demand  for  physicians  is  no 
longer  such  as  to  compel  the  maintenance  of  schools 
with  low  standards. 

THE  TRUE  UNIVERSITY. 

The  true  university  dates  its  inception  in  America 
from  the  founding  of  the  Johns  Hopkins  University, 
which  within  a few  months  has  celebrated  its  twenty- 
fifth  anniversary.  From  this  institution,  with  its  em- 
phatic pronouncement  that  the  extension  of  knowledge 
by  original  investigation  must  constitute  the  very  es- 
sence of  the  true  university,  can  be  directly  traced  the 
origin  of  the  university  idea  in  this  country.  Soon 
Harvard.  Yale,  Columbia  and  Pennsylvania  caught  the 
new  spirit,  and  the  founding  of  the  Clark  University  in 
the  early  ’80s,  with  the  growth  of  Cornell  and  some  of 
the  state  universities,  gave  evidence  of  the  fact  that  the 
university  idea  had  taken  deep  and  abiding  root  in 
American  soil.  Unfortunately,  however,  many  other  col- 
leges, entirely  lacking  the  means,  the  men  or  the  equip- 
ment essential  for  true  university  work,  stimulated  by  a 
feeling  of  rivalry,  became  ambitious  to  pose  under  the 
larger  name.  Mistaking  mere  multiplicity  of  departments 
and  a large  enrolment  of  students  as  the  essential  feat- 
ures of  the  university,  they  promptly  became,  by  a mere 
process  of  rechristening,  nominal  universities.  Natur- 
ally the  next  step  was  to  institute  professional  depart- 
ments, and,  as  in  many  cases,  colleges  of  law,  medicine, 


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dentistry,  pharmacy  and  the  like,  already  established  and 
prosperous,  were  located  in  more  or  less  close  proximity, 
the  ambitious  university  found  it  much  easier  to  expand 
along  these  lines  by  a process  of  amalgamation  than 
by  the  creation  of  wholly  new  departments.  The  pro- 
fessional schools  were,  in  most  cases,  more  than  willing 
to  enter  into  such  an  alliance,  for  they,  too,  had  caught 
the  university  idea  in  the  same  superficial  way,  and 
had  come  to  feel  that  a university  connection  of  some 
sort  was  the  order# of  the  day,  and  that  the  medical 
school  must  be  so  connected  to  be  in  vogue.  Yet  an- 
other motive  was  found  in  many  cases  in  the  rapidly- 
increasing  cost  of  maintenance.  The  introduction  of 
laboratory  methods,  the  necessity  for  salaried  teachers  in 
the  fundamental  branches,  and  for  the  maintenance  of 
hospitals  and  dispensaries  to  provide  adequate  clinical 
material  had  increased  the  cost  of  the  medical  course  be- 
yond the  students  ability  to  pay  for  it  even  when  the 
fees  were  increased  to  twice  those  formerly  charged.  It 
was  obvious  that  governmental  aid  or  private  endow- 
ment must  be  had  and  that  this  could  seldom  be  secured 
by  the  medical  college  as  an  independent  institution. 

THE  NOMINAL  CONNECTION  WITH  A UNIVERSITY. 

The  character  of  the  relationship,  however,  which 
exists  between  the  college  or  university  and  the  medical 
school  has  been  in  the  large  majority  of  cases  purely 
nominal,  as  evidence  of  which  a specific  case  will 
serve.  I have  in  mind  an  institution  which  blos- 
somed forth  in  a few  months  from  a college  with  less 
than  four  hundred  students  into  a university  with  an 
enrolment  of  nearly  twenty-five  hundred.  An  analysis 
of  the  student  list,  however,  discovers  the  fact  that  about 
eight  hundred  of  these  students  were  in  the  medical 
college,  which  had  added  to  its  title  “The  Medical  De- 
partment   University/'  over  four  hundred  were 

in  a dental  college,  similarly  allied,  some  two  hun- 
dred in  a law  school,  and  a large  number  in  a school  of 
pharmacy.  The  number  of  students  in  the  actual  col- 
legiate departments  had  not  increased  nor  had  the  num- 
ber of  members  in  the  faculty,  while  the  courses  offered 
and  the  character  of  the  work  done  had  not  been  ma- 
terially altered.  And  what  was  the  nature  of  the  union 
between  this  “university”  and  its  constituent  professional 


5 


schools?  Purely  nominal.  They  had  not  surrendered 
one  iota  of  their  autonomy.  The  separate  board  of 
trustees  and  faculty  were  in  each  case  retained  intact, 
having  entire  and  unrestricted  control  over  the  finances 
of  the  professional  school,  of  appointments  to  its  faculty, 
of  the  standards  of  admission  and  graduation,  and  of 
all  its  other  affairs.  These  departments  were  located 
several  miles  from  the  university,  and  the  only  visible 
evidence  of  their  connection  with  it,  aside  from  the 
printed  line  on  the  announcements  and  letter  heads,  was 
the  appearance  of  the  president  of  the  university  to  con- 
fer the  degrees  at  the  annual  commencement. 

While  this  example  represents  the  extreme  degree  of 
looseness,  in  such  a connection,  it  differs  only  in  a de- 
gree from  that  of  the  large  majority  of  the  medical 
schools  now  connected  with  universities  in  this  country. 
May  not  the  real  value  of  such  an  alliance,  to  either  the 
university  or  the  professional  school,  be  fairly  ques- 
tioned? There  has  been  a disposition  to  attribute  to 
these  university  connections  the  rapid  progress  which 
has  taken  place  in  medical  education  in  recent  years, 
but  it  is  difficult  to  conceive  how  such  a purelv  nominal 
relation  can  have  had  much  influence  in  this  regard. 
This  progress,  comprising  the  elevation  of  the  stand- 
ards of  admission  and  graduation,  the  lengthening  and 
grading  of  the  curriculum,  the  introduction  of  new 
branches  and  of  improved  methods  of  instruction,  has 
come  about  as  the  inevitable  result  of  the  advancement 
which  has  been  going  on  in  all  lines  of  education.  The 
development  of  the  true  university  and  of  the  university 
spirit  in  America  has  had  much,  indeed  most,  to  do  with 
it,  but  not  through  any  such  nominal  relationship 
as  in  the  case  above  cited.  It  is  a singular  fact  that 
even  in  the  older  medical  schools,  which  were  from  their 
inception  university  departments,  the  relation  of  the 
medical  with  the  general  faculty  has  had  so  little  of 
unity  or  intimacy  about  it.  The  medical  department  is 
usually  removed  by  some  distance  from  the  university 
proper,  the  faculties  never  meet  together,  and  in  almost 
every  respect  the  jnedical  school  is  conducted  as  an  inde- 
pendent institution. 

THE  PROPER  RELATIONSHIP  TO  THE  UNIVERSITY. 

The  largest  service  can  never  be  accomplished  by  the 


6 


medical  school  nor  can  the  fullest  measure  of  advantage 
result  to  it  or  to  the  university  from  such  a purely 
nominal  relationship.  What,  then,  should  be  the  nature 
of  the  union  between  the  medical  school  and  the  uni- 
versity of  which  it  is  a part  ? 

It  must  be  made  an  intimate,  integral  part  of  the  uni- 
versity. Its  financial  management  must  be  given  over 
wholly  to  the  board  of  university  trustees,  a body  of 
laymen  with  large  business  experience,  deriving  no  pe- 
cuniary advantage  from  this  position  and  commanding 
the  fullest  confidence  of  the  community.  Only  by  such 
an  arrangement,  and  the  assurance  of  wise  and  disin- 
terested management  which  it  affords,  can  private  en- 
dowment be  successfully  invited.  It  would  be  of  distinct 
advantage  to  the  university  to  have  at  least  one  medical 
man  on  this  board  of  trustees.  The  medical  teachers 
must  be  members  of  the  university  faculty,  sitting  in 
its  councils  and  having  a voice  in  the  educational  policy 
of  the  whole  institution,  while,  on  the  other  hand,  the 
conduct  of  the  medical  work  should  be  subject  to  the  ad- 
vice and  approval  of  the  general  faculty. 

THE  FUNDAMENTAL  BRANCHES. 

The  teaching  of  the  fundamental  medical  branches 
which  constitute  the  first  two  years  of  the  curriculum,  as 
now  arranged,  should  be  conducted  in  the  corresponding 
university  departments  of  physics,  chemistry,  anatomy, 
zoology,  physiology  and  bacteriology.  Even  pharmacology 
and  fundamental  pathology  should  be  so  taught,  for  in 
the  widest  and  best  sense  these  sciences  are  branches  of 
general  learning  and  should  be  provided  for  in  the  uni- 
versity quite  apart  from  their  medical  significance.  The 
advantages  of  such  an  arrangement  are  many  and  im- 
portant. It  will  obviate  the  expensive  duplication  of 
departments  as  they  exist  now  under  the  prevailing  sys- 
tem. Most  of  these  branches  are  at  present  taught  in 
the  university  proper,  in  well-appointed  laboratories,  by 
men  who  are  devoting  their  lives  to  research  and  teach- 
ing in  their  respective  lines,  yet  at  the  medical  school 
of  the  same  institution  this  expensive  equipment  is 
duplicated  and  another  corps  of  teachers  employed, 
either  on  a similar  basis,  or  more  often  as  men  who  are 
primarily  practitioners  of  medicine,  only  incidentally 
teaching  these  subjects  in  a perfunctory  way  while  wait- 


ing  for  some  incumbent  of  a clinical  chair  to  vacate  by 
death,  resignation  or  otherwise,  and  thus  make  possible 
the  fulfilment  of  their  real  ambition.  Of  more  im- 
portance is  the  fact  that  these  subjects  can  only  be 
taught  in  the  right  way  in  the  university  proper,  for 
only  there  can  they  be  so  pursued  as  to  lay  a broad, 
thorough  foundation  for  their  subsequent  application 
to  clinical  medicine. 

MEDICINE  AS  APPLTED  SCIENCE. 

Medicine  is  applied  science.  Its  practice  consists  in 
the  application  of  the  principles,  facts  and  methods  of 
chemistry,  anatomy,  etc.,  to  the  study  and  treatment  of 
the  diseases  and  accidents  of  the  living  body.  In  the 
pursuit  of  any  applied  science  it  is  surely  the  logical 
method  to  master  the  general  principles  and  methods 
first  and  to  proceed  therefrom  to  a study  of  their  appli- 
cation in  any  specific  direction.  Fundamentally  the 
chemistry  which  the  physician  needs  to  know  is  quite 
the  same  as  that  required  by  the  metallurgist,  the  man- 
ufacturing chemist,  the  pharmacist,  or  one  in  any  other 
vocation  where  chemistry  is  concerned.  It  is  only  in  the 
application  of  chemistry  along  these  special  lines  that 
the  methods  differ. 

The  medical  school  has  for  years  been  attempting  to 
teach  its  students  the  fundamentals  of  chemistry  and 
their  specific  application  at  the  same  time.  In  the  short 
course  of  two  five  months*  sessions  there  seemed  to  be  no 
escape  from  this.  But  what  was  the  result?  The  stu- 
dent, crowded  for  time  and  jealous  of  every  minute, 
sought  to  learn,  as  his  professor  sought  to  teach  him, 
those  isolated  facts  of  chemistry  which  seemed,  at  the 
time,  to  have  most  direct  bearing  on  medicine.  Yet  no 
teacher,  however  wise,  much  less  any  student,  could  pos- 
sibly anticipate  the  chemical  knowledge  which  might 
be  of  medical  import  a few  years  in  the  future,  in  the 
rapidly-progressing  art  and  science  of  medicine.  The 
result  was  a half  knowledge  mostly  soon  forgotten.  If 
the  medical  man  is  to  have  a groundwork  in  chemistry 
which  will  enable  .him  to  keep  abreast  with  his  pro- 
fession, he  must  be  so  trained  in  the  fundamental  facts 
and  principles  as  to  enable  him  to  keep  in  touch  with  the 
advances  in  that  science,  to  read  its  literature  intelli- 
gently and  to  apply  the  frequent  new  discoveries  to  his 


8 


daily  work.  To  illustrate:  ten  years  ago  the  remark- 
able facts  of  physical  chemistry  relative  lo  the  behavior 
of  mineral  salts  in  very  dilute  solution — the  so-called 
ionic  condition  of  matter— would  have  been  pronounced 
by  any  chemist  as  among  the  most  theoretical  and  im- 
practical facts  of  that  science,  yet  already  the  investiga- 
tions of  Loeb  and  his  pupils  have  demonstrated  these 
facts  to  have  a most  important  bearing  on  physiology, 
pathology  and  pharmacology.  Indeed,  it  is  not  too 
much  to  say  that  these  facts  of  physical  chemistry, 
which  we  owe  to  Arrhenius  and  van  PHoff,  offer  an  ap- 
parent promise  of  a solution  of  more  problems  in  the 
fundamental  and  practical  medical  sciences  than  any 
others  no;w  known  to  us.  Few  physicians  trained  by  the 
older  methods  of  the  medical  school,  have  been  able  to 
keep  pace  with  these  developments  or  even  to  read  them 
understanding^,  but  to  the  medical  man  who  received 
an  adequate  training  in  chemistry  in  a college  or  univer- 
sity, they  present  little  difficulty. 

What  has  been  said  in  reference  to  chemistry  is  equally 
true  of  anatomy,  both  gross  and  microscopic,  of  neu- 
rology, embryology,  physiology  and  physiologic  chem- 
istry, of  bacteriology  and  pathology.  Studied  primarily 
in  the  atmosphere  and  by  the  methods  of  the  univer- 
sity the  ground-work  of  these  sciences  is  laid  in  a broad 
and  comprehensive  manner  wdiich  enables  the  student 
to  follow  their  progress  in  later  years  and  their  specific 
application  to  medicine  and  surgery  is  easily  acquired. 
Pursued  in  the  illogical,  unsystematic  manner  of  former 
years,  they  are  never  mastered  and  too  often  the  physi- 
cian soon  awakes  to  the  unpleasant  consciousness  that 
the  facts  acquired  at  such  a laborious  expenditure  of 
time  and  energy  have  most  of  them  flown  from  his  mem- 
ory. Not  only  has  he  failed  to  keep  abreast  with  the 
newer  knowledge — he  has  forgotten  the  old.  Life  is 
too  short  and  time  too  precious  to  be  wasted  in  memo- 
rizing facts  that  must  soon  be  forgotten. 

THE  BENEFITS  OF  THE  UNIVERSITY  ATMOSPHERE. 

Great  benefit  will  come  to  the  student  from  two  or 
three  years  spent  in  the  atmosphere  of  the  university 
in  the  daily  companionship  of  men  who  are  masters  in 
their  several  departments  and  who,  as  investigators,  are 
seeking  to  add  new  knowledge  by  their  own  discoveries. 


9 


The  spirit  and  method  of  the  research  worker  is  exactly 
that  of  the  successful  practitioner  of  medicine  whose 
every  case  is  a problem,  never  exactly  like  any  other 
that  has  been  met  before.  Such  problems  are  never 
satisfactorily  solved  by  routine  rules  of  diagnosis  and 
treatment,  but  only  by  the  exact  painstaking  examina- 
tion of  the  facts  in  the  particular  case  and  the  applica- 
tion thereto  of  the  principles  of  anatomy,  physiology 
and  pathology.  The  successful  practitioner  is  he  who 
is  most  completely  a master  of  this  “investigative” 
ability,  and  who  avoids  most  effectually  the  pressing 
temptation  to  become  a “routine”  doctor. 

Of  the  influence  on  the  student  of  the  social  and 
intellectual  life  of  the  university  it  is  hardly  neces- 
sary to  speak.  No  environment  is  more  conducive  to 
the  development  of  a strong,  broad-minded  influential 
man  and  citizen,  and  that  is  what  we  would  wish  every 
physician  to  be.  The  transfer  of  the  teaching  of  the 
fundamental  branches  to  the  halls  and  laboratories  of 
the  university  proper,  will  do  more  toward  the  creation 
of  a strong  and  influential  profession  than  any  other 
plan  that  has  yet  been  tried.  For  this  reason,  and  be- 
cause it  is  adaptable  to  so  many  medical  schools,  it 
seems  to  me  to  be  the  most  progressive  and  far-reaching 
movement  which  has  yet  been  made  in  medical  education. 

THE  PURPOSES  OF  THE  UNIVERSITY  MEDICAL  SCHOOL. 

The  purposes  of  the  university  medical  school,  organ- 
ized on  the  lines  indicated,  will  be  broader  and  more 
comprehensive  than  those  of  the  existing  medical 
schools  because  of  its  larger  facilities  and  possibilities. 
They  may  be  briefly  summarized : 1.  The  preparation 

of  men  for  the  practice  of  medicine — undergraduate 
instruction;  2,  the  training  of  selected  students  for 
teaching  and  research  work ; 3,  to  offer  opportunities 
for  practitioners  to  keep  pace  with  the  advance  of  medi- 
cine— such  as  are  now  afforded  by  the  policlinic 
schools;  4,  the  preparation  of  men  for  public  health 
service;  5,  to  extend  the  bounds  of  medical  knowledge 
by  affording  opportunity  and  encouragement  for  re- 
search work  ; 6,  to  investigate  and  pronounce  authorita- 
tively on  alleged  new  discoveries  bearing  on  medicine, 
and  7,  to  educate  the  public  along  medical  lines  by  the 
methods  of  university  extension. 


10 


THE  UNDERGRADUATE  STUDENT. 

The  preparation  of  young  men  for  the  practice  of 
medicine  in  the  usual  sense  of  the  term,  must  always 
constitute  the  largest  and  most  important  function  of 
the  university  medical  school.  And  by  this  is  meant  the 
education  of  students  for  the  humblest  as  well  as  the 
most  exalted  walks  of  the  profession.  Time  was  when 
the  college  or  university  was  an  exclusive  institution, 
whose  members  were  disposed  to  feel  themselves  re- 
moved from  the  world  at  large,  set  apart  for  certain  spe- 
cial and  exalted  duties.  Happily  that  time  is  past  and 
the  modern  university  seeks  above  all  things  to  keep  in 
touch  with  and  to  supply  the  needs  of  the  world  of 
affairs,  wherever  and  whenever  it  can  do  so.  Witness 
the  rapid  growth  of  the  university  extension,  of  corres- 
pondence courses,  of  short  courses  in  agriculture,  peda- 
gogy and  the  like,  and  of  the  establishment  of  depart- 
ments of  agriculture,  economics,  banking  and  com- 
merce, journalism  and  other  ultra-practical  branches. 

TIIE  STANDARDS  OF  ADMISSION. 

The  attitude  which  the  university  medical  school  as- 
sumes in  regard  to  this  matter  will  largely  determine 
its  standards  of  admission  and  graduation.  While  the 
university  must  stand  always  for  the  highest  practicable 
requirements,  it  seeks  not  to  cut  itself  off  from  the 
education  of  men  who  are  needed  for  the  work  of  the 
world  by  placing  these  standards  beyond  the  reach  of  all 
but  a few.  Its  requirements  must  be  adjusted  to  the 
conditions  of  the  times  and  be  gradually  raised  as  the 
community  is  educated  up  to  their  endorsement  and  to 
the  adequate  appreciation  and  support  of  the  men  whom 
the  university  has  trained.  It  would  be  a great  mis- 
fortune if  the  university  medical  school  were  to  confine 
itself  to  the  instruction  of  the  select  few  who  would 
find  adequate  recompense  for  their  expensive  training 
only  in  the  higher  walks  of  professional  life.  Such  a 
policy  would  inevitably  result  in  a wide  and  ever  widen- 
ing breach  between  the  few  schools  of  this  class,  and 
the  great  number  of  medical  colleges  with  low  stan- 
dards to  whom  would  fall  the  teaching  of  the  rank  and 
file  of  the  profession. 

We  hear  much  of  an  ideal  standard  of  admission  to 
the  medical  school.  And  what  may  that  be?  Surely 


11 


not  the  bachelor's  degree,  for  as  conferred  in  this  coun- 
try by  the  thousand  or  more  institutions  empowered 
to  grant  it,  it  is  no  standard  at  all,  its  significance  rang- 
ing from  less  than  many  high  school  diplomas  to  that 
conferred  by  the  highest  grade  universities.  One  insti- 
tution, to  my  knowledge,  admits  students  from  the 
grammar  school,  confers  a bachelor's  degree  after  two 
sessions  of  fifty  weeks  each,  allowing  the  student  during 
the  same  period  to  complete  the  course  for  the  degree 
of  Ph.G.  If  knowledge  of  certain  specific  branches 
be  demanded  in  addition  to  the  bachelor's  degree,  may  it 
not  well  be  asked  why,  if  these  are  the  essential  things, 
the  degree  should  be  made  a prerequisite  at  all? 

The  degree  which  affords  the  nearest  approach  to  an 
ideal  is  that  of  Ph.D.  This  degree  has  been  guarded 
with  much  more  care  in  America  than  any  other.  It 
certifies,  when  from  any  standard  institution,  that  the 
student  has  not  only  pursued  a seven  years'  course  of 
collegiate  instruction,  but  that  he  has  given  evidence  of 
capacity  as  an  investigator — of  the  very  qualities  of 
mind,  indeed,  which  are  most  demanded  in  the  study 
and  practice  of  medicine.  But  would  any  one  contend 
that  such  a requirement  could  reasonably  be  exacted 
of  all  candidates  for  admission  to  the  medical  college 
under  the  conditions  and  emoluments  of  private  prac- 
tice at  present  in  vogue?  Such  a demand  would  be 
“ideal"  under  ideal  conditions  and  an  ideal  apprecia- 
tion bv  the  public,  of  the  physician's  merit  and  the  com- 
pensation due  him.  but  the  truly  “ideal"  standard,  in 
the  most  useful  sense  of  the  word,  is  that  which  best 
fits  the  graduate  in  medicine  for  the  conditions  of  his 
time,  and  this  must  be,  for  a long  time  to  come,  not  a 
fixed  but  a gradually  increasing  standard. 

THE  TRULY  IDEAL  STANDARD. 

And  what  may  be  fairly  demanded  under  existing 
conditions?  Bearing  in  mind  the  readiness  with  which 
the  medical  schools  have  met  the  rapidly  increasing  de- 
mands of  the  last  decade — demands,  in  large  part  cre- 
ated by  the  schools  themselves — there  can  reasonably 
be  exacted  in  the  near  future,  by  every  medical  school, 
a four-year  high-school  education,  and,  in  addition,  two 
years  of  college  work,  insisting  that  this  be  partly  in 
chemistry,  physics,  biology,  mathematics,  English,  Ger- 


12 


man  and  French — branches  which  are  especially  need- 
ful as  a preparation  for  medical  work.  And  with  such 
a preparatory  course  the  student  can  procure  the 
bachelor’s  degree  in  the  university  medical  school  by 
applying  his  credits  for  the  first  two  years  of  his  purely 
medical  work  on  the  course  for  that  decree,  without 
in  any  degree  doing  violence  to  existing  university  pro- 
cedure. The  fundamental  medical  branches,  if  taught 
in  the  university  itself,  by  university  teachers  and 
university  methods,  have  quite  the  same  culture  value 
as  have  geology,  astronomy  or  any  of  the  other  sciences, 
and  credits  for  work  in  these  branches  should  count 
on  the  scientific  or  arts  course  in  exactly  the  same  way. 
Under  such  an  arrangement  the  average  student  is  able 
to  secure  the  degrees  of  B.S.  and  M.D.  in  from  six  to 
six  and  a half  years  from  the  date  of  his  entrance  to 
college,  should  begin  his  medical  work  at  the  age  of 
21  or  22,  and  be  launched  into  practical  life,  with  a year 
of  hospital  training,  at  26  or  27.  The  problem  of 
launching  young  men  into  professional  life  with  an 
adequate  training  at  an  earlier  age  than  has  been  pos- 
sible under  the  existing  methods,  has  been  much  dis- 
cussed by  leading  educators.  In  some  of  our  best  uni- 
versities the  course  for  the  bachelor’s  degree  has  been 
shortened  to  three  years.  The  plan  here  outlined,  of 
telescoping  the  literary  or  scientific  with  the  profes- 
sional course,  where  they  so  nearly  correspond,  seems 
to  offer  a much  more  logical  and  satisfactory  solution. 
The  advantage  to  many  students  of  a complete  colle- 
giate course  of  four  years,  as  precedent  to  the  medical 
school,  is  clearly  recognized,  and  every  inducement 
should  be  offered  such  students  to  prolong  their  course 
of  preparation.  The  right  of  any  school  to  insist  on  a 
four  years’  college  course  as  a standard  of  admission 
may  not  be  gainsaid.  It  is  only  meant  to  contend  that 
it  would  be  unfortunate  for  the  community  if  all  of  the 
high-grade  schools  were  to  adopt  such  a policy. 

Should  any  special  medical  degree  be  conferred  on 
the  student  who  has  presented  a bachelor’s  degree  for 
admission?  Not  unless  he  gives  evidence  in  his  medi- 
cal course  of  the  superior  capacity  and  attainments, 
which  he  should  have  derived  from  his  longer  course  of 
preparation.  And,  if  he  does  this,  if  he  manifests  the  in- 
vestigative ability,  and  accomplishes  research  work  in 


13 


the  medical  branches  similar  to  that  wmch  is  demanded 
for  a master’s  degree  or  the  degree  of  doctor  of  philoso- 
phy, one  of  these  degrees  should  be  conferred. 

THE  PREPARATION  OE  TIIE  TEACHER  AND  INVESTIGATOR. 

Recent  changes  in  the  methods  of  medical  education 
have  greatly  increased  the  demand  for  men  who  have 
been  especially  trained  for  the  work  of  teaching  and 
investigation  and  who  prepare  themselves  with  the  in- 
tention of  devoting  their  lives  to  such  work.  Not  the 
least,  therefore,  of  the  functions  of  the  university  med- 
ical school  will  be  the  education  of  this  class  of  stu- 
dents. And  how  shall  these  students  be  selected  ? Shall 
the  entrance  requirements  for  these  pupils  be  different 
from  those  exacted  of  the  larger  group  who  are  prepar- 
ing for  the  practice  of  medicine?  I believe  not,  for  no 
plan  of  examination  can  ever  enable  a faculty  to  select 
such  men  so  wisely  as  will  the  observation  of  their 
daily  work  in  the  regular  course  of  instruction.  One 
of  the  most  capable  and  successful  investigators  and 
teachers  whom  I have  known  possessed  only  a high 
school  diploma  when  he  entered  the  medical  school,  yet 
in  his  sophomore  year  he  accomplished  a piece  of  re- 
search work  which  would  have  done  credit  to  a doctor 
of  philosophy,  and  immediately  after  his  graduation  he 
was  appointed  to  a responsible  university  position, 
which  he  fills  with  distinction.  It  is  not  at  all  certain 
that  this  young  man  has  done  an  unwise  thing  in  fore- 
going a collegiate  career.  True,  his  case  is  somewhat 
of  an  exception  to  the  general  rule,  but  provision  must 
be  made  for  such  exceptions.  Furthermore,  it  is  of 
mutual  advantage  to  the  research  worker  and  to  the  or- 
dinary student,  that  they  be  educated  in  the  same  insti- 
tution and  in  daily  contact  with  each  other — to  the 
ordinary  student  because  it  is  of  the  greatest  advantage 
to  him  that  he  should  be  in  the  atmosphere  and  should 
catch  the  investigation  spirit;  from  the  standpoint  of 
the  research  worker  because  the  selection  of  such  men 
can  best  be  made  from  large  groups  of  students  who  are 
revealing  their  special  abilities  and  characteristics  to 
their  teachers  in  their  daily  work. 

THE  UNIVERSITY  POLICLINIC. 

In  every  progressive  occupation,  reports  of  progress 
from  all  over  the  world  find  their  way  most  quickly  to 


14 


the  large  centers  and  men  who  are  themselves  engaged 
in  teaching  and  investigation  are  most  likely  to  keep 
informed  as  to  the  new  discoveries  which  are  being 
made.  The  physician  engaged  in  a busy  practice,  far 
removed  from  snch  a center,  finds  it  difficult,  even  with 
the  abundant  current  literature  and  the  aid  of  a good 
library  and  laboratory,  to  keep  thoroughly  abreast  of 
the  times.  He  finds  it  of  advantage,  therefore,  to  seek 
such  a center  from  time  to  time,  to  spend  a few  weeks 
in  special  postgraduate  study.  The  necessity  for  this 
sort  of  review  on  the  part  of  the  general  practitioner 
has  been  especially  pressing  during  the  last  few  years, 
owing  to  the  enormous  and  rapid  advance  of  the  medical 
sciences.  How  great  has  been  the  demand  for  facilities 
in  this  direction  is  evidenced  by  the  large  number  of 
policlinic  and  postgraduate  schools  which  have  come 
into  existence  since  1882.  These  institutions  have  met 
a real  need  and  have  been  of  great  service,  but  it  is  not 
too  much  to  say  that  they  have  not  been  organized 
on  the  best  possible  basis  nor  do  they  offer  facilities  for 
the  highest  kind  of  work.  A great  varietv  of  work  is 
demanded  by  these  policlinic  students;  some  need 
courses  even  more  fundamental  than  the  ordinary 
undergraduate,  for  whole  new  sciences,  like  bacteriology, 
have  been  created  since  these  gentlemen  took  their  med- 
ical degrees;  some  few  are  really  competent  to  enter 
on  the  study  of  and  preparation  for  a specialty,  while 
a few  have  the  necessary  equipment  and  qualities  of 
mind  demanded  by  research  work  of  a high  order.  To 
adequately  supply  these  various  demands,  needs  an  in- 
stitution of  large  resources,  a large  faculty,  and  very 
large  hospital  facilities.  Only  the  university  medical 
school  has  anything  like  the  equipment  necessary  for 
this  work,  and  the  instruction  of  practitioners,  in  the 
broadest,  most  complete  manner,  will  constitute  one  of 
its  important  functions.  The  university  policlinic  will 
not  be  conducted  on  the  “Make-a-specialist-of-vou-while- 
you-wait”  policy  that  has  too  often  prevailed,  but  for  the 
sound  and  legitimate  purpose  of  enabling  the  practi- 
tioner to  continue  his  student-life,  and  to  keep  in  touch 
with  the  new  knowledge  and  improved  methods  so  that 
he  may  utilize  them  in  his  daily  work.  Its  laboratories 
and  libraries  will  be  at  all  times  open  to  the  physicians 
in  proximity  to  the  university  that  they  may  the  more 


15 


thoroughly  and  exhaustively  study  their  cases  by  the 
methods  and  apparatus  and  the  literature  not  otherwise 
at  their  command. 

THE  EDUCATION  0 F THE  SANITARIAN. 

Courses  in  state  medicine  and  sanitary  science  are  a 
pressing  need  of  the  time.  Preventive  medicine  has 
profited  far  more  than  curative  medicine  by  the  dis- 
coveries of  recent  years,  especially  in  bacteriology.  Our 
hope  for  the  future  lies  in  the  education  of  the  public 
in  regard  to  matters  already  well  known  to  the  profes- 
sion, in  the  enactment  of  suitable  laws,  and  in  the  effi- 
ciency of  properly  trained  health  officers,  city,  state  and 
national.  State  medicine  constitutes  a distinct  specialty 
and  its  successful  pursuit  demands  a particular  course 
of  study  which  should  extend  over  at  least  two  years. 
Nowhere  can  the  facilities  for  such  a course  of  post- 
graduate instruction  be  adequately  afforded  excepting 
in  the  university,  with  its  many  departments,  its  large 
corps  of  trained  investigators  and  teachers,  and  its  well- 
appointed  laboratories.  In  the  department  of  geology, 
there  may  be  studied  the  character  of  rocks  and  soils  and 
of  physiography  in  their  relation  to  water  supply, 
drainage,  sewage  disposal,  and  the  like;  in  the  depart- 
ment of  chemistry,  instruction  in  water  analysis,  toxi- 
cology and  the  chemistry  of  food  and  drug  adulteration, 
will  be  offered ; in  the  department  of  zoology,  a knowl- 
edge may  be  acquired  of  animal  parasites  and  of  the 
microscopic  examination  of  animal  foodstuffs  for  their 
detection;  the  department  of  bacteriology  will  occupy 
a conspicuous  position  in  this  course  in  state  medicine 
for  the  study  of  the  bacteriologic  examination  of  water, 
of  milk,  and  other  foods,  and  the  detection  of  the  vari- 
ous pathogenic  organisms;  the  theories  and  methods  of 
disinfection  should  be  fundamentally  studied;  in 
the  department  of  pathology,  connected  as  it  must  be 
with  a large  hospital,  there  will  be  taught  the  methods 
of  conducting  a postmortem  examination,  especially  in 
connection  with  medicolegal  cases.  And,  finally,  prac- 
tical instruction  must  be  afforded,  in  the  health  depart- 
ment of  the  city  itself,  in  such  matters  as  house  inspec- 
tion, the  testing  of  sewer  traps  and  other  plumbing, 
public  vaccination,  the  detection  of  cases  of  infectious 
diseases,  the  institution  and  maintenance  of  quarantine, 


16 


the  registration  of  vital  statistics,  the  best  methods  of 
educating  the  community  by  the  circulation  of  pamph- 
lets, through  the  public  press,  and  otherwise.  There  are 
few  health  officers  who  would  not  heartily  cooperate 
with  the  university  in  offering  such  facilities  as  this, 
as  these  students  can  be  of  great  service  to  the  health 
department  in  the  conduct  of  its  daily  work,  and  they 
would  thus  make  abundant  return  for  the  instruction 
received. 

THE  PROMOTION  OF  RESEARCH  WORK. 

The  obligation  of  the  university  and  of  everyone 
connected  with  it.  to  extend  the  bounds  of  knowledge  by 
independent  research,  is  now  universally  recognized. 
Investigation  of  the  unknown  as  distinguished  from 
mere  appreciative  study  of  the  work  of  others,  consti- 
tutes the  keynote  of  the  modern  university,  and  this  will 
be  no  less  emphatically  a feature  of  the  medical  than 
of  its  other  departments.  Investigation  is  essential, 
however,  not  simply  that  the  bounds  of  knowledge  may 
be  extended,  but  that  the  spirit  and  method  of  research 
may  be  inculcated  in  every  student.  It  is  important 
that  this  fact  be  kept  in  mind  for  a thorough  apprecia- 
tion of  this  purpose  will  affect  most  decidedly  the  atti- 
tude of  the  teacher  toward  his  pupils.  He  is  not  dis- 
charging his  full  duty  nor  doing  the  largest  service 
when  he  confines  his  attention  and  devotes  his  best 
energies  to  the  few  selected  students  who  demonstrate 
special  capacity  for  such  work  and  give  promise  of  de- 
veloping into  competent  investigators.  Naturally,  his 
interest  will  be  especially  aroused  in  this  group  of  pu- 
pils. but  he  has  no  less  an  obligation  to  inculcate  the 
same  spirit  and  to  train  in  the  same  methods  of  work 
the  less  capable  individuals  who  are  preparing  for  the 
ordinary  practice  of  medicine. 

RESEARCH  IN  THE  CLINICAL  BRANCHES. 

In  several  American  universities  superior  opportuni- 
ties for  investigation  in  the  fundamental  medical 
sciences  of  anatomy,  physiology,  chemistry,  bacteri- 
ology,  pharmacology,  embryology,  physiological  chem- 
istry, and  pathology,  are  now  afforded,  and  research  work 
of  a high  order  is  being  conducted  in  these  branches. 
Quite  as  important,  however,  are  the  clinical  branches 
of  medicine  and  it  remains  for  the  university  medical 


17 


school  to  provide  the  men  and  the  facilities  to  take 
up  research  work  along  these  lines.  This  means,  in  the 
first  place,  the  provision  of  a corps  of  teachers  in  each 
of  the  clinical  branches  who,  divorced  entirely  from 
the  labor  and  distractions  of  active  practice,  may  de- 
vote themselves  unreservedly  to  teaching  and  investiga- 
tion in  their  several  departments.  This  does  not  by 
any  means  imply  that  there  will  be  no  place  in  the 
faculty  of  such  a school  for  the  teacher  who  is  at  the 
same  time  a practitioner  of  medicine.  Medicine,  as  has 
been  said  before,  is  an  applied  science  and  in  its  teach- 
ing force  there  will  always  be  need  of  men  who  are 
daily  engaged  in  the  application — the  regular  practice — 
of  their  vocation.  A large  part  of  the  necessary  instruc- 
tion of  the  student  can  only  be  accomplished  by  such 
teachers.  Nor  will  the  active  practitioner  be  excluded 
from  the  privileges  and  obligations  of  research.  Most 
of  the  advances  in  medicine  which  have  been  made  up 
to  the  present  time  have  been  accomplished  by  physi- 
cians in  active  practice.  Doubtless  some  of  these  men 
might  have  accomplished  more  in  the  way  of  discovery 
had  they  been  freed  from  the  exacting  duties  of  practice, 
but  we  may  not  say  this  of  them  all.  Some  of  these  dis- 
coverers doubtless  found  in  the  conditions  of  their  daily 
work  the  very  incentive  and  environment  which  was 
essential  to  their  investigations.  Certainly  this  has 
been  true  in  the  other  applied  sciences,  as,  for  example, 
in  electrical,  mechanical  and  chemical  engineering, 
some  of  the  most  important  discoveries  in  which,  not 
only  in  methods  of  application,  but  in  fundamental 
principles  have  been  made  by  men  who  were  practicing 
engineers. 

In  the  second  place,  investigation  in  the  clinical 
branches  demands  the  provision  of  special  hospitals,  ab- 
solutely under  the  control  of  the  university,  perfectly 
equipped  and  adequately  supported,  where  patients  may 
be  studied  under  conditions  which  have  not  vet  ob- 
tained in  full  measure  in  any  hospitals  with  which  I am 
acquainted.  It  will  be  of  advantage,  if  there  can  be 
brought  together  in  such  a hospital,  from  time  to  time, 
groups  of  cases  of  the  same  or  allied  disorders.  What 
might  not  be  discovered,  for  example,  from  an  exhaus- 
tive study  of  a group  of  forty  or  fifty  cases  of  diabetes 
mellitus,  gathered  in  one  building  for  a few  months. 


18 


where  the  condition  could  be  absolutely  controlled? 
That  every  such  hospital  must  have  abundant  labora- 
tory facilities  and  a corps  of  trained  assistants  goes  with- 
out saying. 

THE  INVESTIGATION  OF  ALLEGED  DISCOVERIES. 

From  time  to  time  there  arise  in  medicine  fads  and 
Asms  and  Apathies,  loudly  heralded  by  their  promul- 
gators as  the  only  and  long-awaited  panacea  for  all  the 
ills  that  flesh  is  heir  to,  and  such  has  been  the  history 
of  the  world  since  time  began.  Many  such  claimants 
for  popular  credence  carry  their  own  refutation  and  are 
no  more  worthy  of  investigation  by  the  university  than 
would  be  the  claims  of  the  newspaper  weather-prophet 
or  the  street-corner  astrologer  and  horologist.  Some  of 
these  passing  fancies,  however,  take  a strong  hold  on  the 
public  mind,  and  much  harm  results,  before  the  utter 
falsity  of  the  fad  is  demonstrated,  or.  possibly,  the  small 
kernel  of  truth  winnowed  from  the  mass  of  chaff.  Often 
it  would  seem  as  if  the  credulity  of  the  public  were 
in  direct  ratio  to  the  absurdity  of  the  claims  of  the 
system.  The  fancied  division  in  the  public  mind  of 
scientific  medicine  into  so-called  “schools,”  and  the 
supposed  animosity  of  the  adherents  of  these  schools  to- 
ward each  other,  has  precluded  the  possibility  of  any 
investigation  and  pronouncement  from  the  independent 
medical  college  having  any  considerable  weight  or  au- 
thority. May  not  the  university  with  its  large  faculty, 
representing  many  phases  of  thought,  and  free  from  the 
suspicion  of  prejudice,  perform  an  important  service 
to  the  community  by  the  impartial  investigation  of 
such  claimants  as  seem  at  all  worthy  of  serious  con- 
sideration, and  a candid  statement  of  the  facts?  In  the 
broad  open  spirit  of  liberality  and  desire  for  the  truth, 
which  should  characterize  the  university,  the  advocates 
of  any  new  system  or  Apathy  might  properly  be  invited 
to  present  their  claims  before  the  faculty  or  a commis- 
sion to  be  selected  for  that  purpose.  Such  an  investi- 
gation as  that  conducted  under  the  auspices  of  the  uni- 
versity of  Pennsylvania  a few  years  ago — the  Seybert 
Commission  for  the  investigation  of  spiritualism — 
occurs  as  an  illustration  of  the  thought  here  presented. 

UNIVERSITY  EXTENSION  AS  RELATED  TO  MEDICINE. 

If  the  beneficent  results  to  the  recent  enormous  ad- 


19 


vance  in  our  knowledge  of  preventive  medicine  are 
to  be  realized  in  any  large  measure,  this  can  only  be  by 
means  of  the  education  of  the  public  in  matters  of  per- 
sonal and  community  hygiene.  The  medical  profession 
has  been  remiss  in  this  direction,  but  this  has  been  in 
large  part  owing  to  the  difficulty  of  addressing  the  pub- 
lic without  violating  the  established  ethics  of  the  pro- 
fession. The  practitioner,  competent  to  give  instruc- 
tion, has  hesitated  to  do  so  because  of  the  certain  im- 
putation of  ulterior  motives,  the  charge  that  he  was 
seeking  to  exploit  his  knowledge  and  so  secure  his  own 
aggrandizement.  A great  work  awaits  the  university 
medical  school  which  it  can  accomplish  by  adapting  to 
this  purpose  the  university  extension  methods,  which 
have  been  so  successful  in  other  branches  of  learning. 
Especially  available  for  this  service  as  lecturers  and 
writers  will  be  those  members  of  the  medical  faculty 
who  are  not  engaged  in  active  practice,  and  to  whom, 
therefore,  no  suspicion  of  improper  motives  can  attach. 
The  vital  and  well-established  facts  in  reference  to  in- 
fectious diseases,  etc.,  advice  in  reference  to  personal 
hygiene,  clothing,  food ; the  abuse  of  intoxicants,  the 
need  of  legislation  in  reference  to  sanitary  matters 
and  the  enormous  possibilities  of  wise  enactments — 
these  are  but  some  of  the  items  which  may  be  effectively 
presented  to  the  public  by  means  of  the  university  ex- 
tension and  correspondence  courses,  articles  in  the 
newspapers  and  popular  magazines,  and  through  other 
avenues  of  instruction.  Existing  organizations  like 
the  social  clubs  for  either  sex,  university  extension  cen- 
ters, churches,  and  the  like,  may  be  readily  utilized  in 
this  work. 

THE  METHODS  OF  THE  UNIVERSITY  MEDICAL  SCHOOL. 

The  methods  of  the  university  medical  school  will 
differ  in  some  respects  radically  from  those  which  have 
heretofore  obtained.  While  didactic  and  so-called  clini- 
cal instruction  to  classes  of  200  or  300  students  may 
continue  to  have  place,  that  place  will  be  a very  limited 
one.  Students  must  be  taught  singly  or  in  small  groups 
in  the  laboratory,  at  the  bedside,  and  in  the  dispensary, 
where  they  may  train  their  faculties  and  acquire  knowl- 
edge at  first  hand  by  seeing,  hearing  and  handling 
things,  instead  of  at  second-hand  by  merely  reading  or 


20 


hearing  what  some  one  else  has  had  to  say  about  them. 
Then,  too,  education  and  not  the  imparting  of  informa- 
tion will  be  the  prime  subject  of  instruction.  In  the 
ten  months  formerly  available  there  seemed  so  much 
knowledge  to  impart  that  there  appeared  to  be  time  for 
little  else,  but  with  the  thirty  to  thirty-six  months  now 
occupied  by  the  medical  course,  and  with  the  obvious 
impossibility  of  imparting  any  considerable  fraction  of 
our  medical  store  in  thrice  that  time,  it-  has  come  to  be 
realized  that  the  actual  facts  selected  for  the  students 
acquisition  are  of  minor  importance,  but  that  it  is  a vital 
matter  that  he  acquire  the  ability  to  observe  accurately, 
record  clearly  and  concisely  and  to  think  logically  along 
medical  lines.  This  means  that  the  scheduled  work  of 
the  curriculum  must  consume  fewer  hours  of  the  day — 
never  to  exceed  six — that  the  remainder  of  his  working 
day  may  be  spent  in  the  library,  or  in  his  room  learning 
to  use  medical  literature  properly,  to  write  clearly  and 
to  think  ! to  think ! to  think ! It  is  surprising  how  ab- 
surdly overcrowded,  and  how  utterly  unbalanced  the 
curricula  of  most  of  our  medical  schools  have  grown. 
In  not  a few  of  them,  eight  and  even  nine  hours  of 
scheduled  work  being  daily  demanded. 

THE  ELECTIVE  SYSTEM. 

Nothing  offers  a more  ready  and  satisfactory  solution 
of  this  difficulty  than  the  elective  system — so  long  and 
successfully  in  vogue  in  some  institutions  of  general 
learning  and  recently  adopted,  in  whole  or  in  part,  by 
some  medical  schools.  It  may  be  defined  as  that  plan 
by  which  a student,  pursuing  a course  for  a degree, 
is  allowed  some  choice  in  the  studies  he  shall  pursue, 
in  his  methods  of  study  and  of  the  teachers  who  shall 
instruct  him ; to  adapt,  in  a word,  his  course  of  study  to 
his  tastes,  his  ability  and  his  needs.  It  finds  its  raison 
d'etre  in  two  fundamental  and  obvious  facts : the  vast- 
ness of  knowledge  and  the  variability  of  individuals. 
If  it  were  possible  to  encompass  all  medical  knowledge 
within  the  limits  of  a four  years*  course  of  study,  or  if 
it  were  possible  to  select  for  all  students  alike  those 
facts  which  are  most  essential  for  every  one  of  them  to 
know,  then  the  question  of  curriculum  would  present 
little  difficulty.  Neither  of  these  things  is  possible  and 
therefore  the  items  of  information  which  are  acquired 


21 


by  each  student,  exclusive  of  a few  of  the  fundamental 
and  important  truths  in  each  branch,  are  not  of  neces- 
sity nor  with  advantage,  the  same  for  each  student. 
On  the  other  hand,  students  differ  very  widely  in  mental 
make-up,  and  no  plan  of  education  can  be  successful 
in  developing  the  best  there  is  in  each  man  which  fails 
to  take  cognizance  of  this  fact  and  adapt  its  course  of 
preparation  to  each  individual,  or,  rather,  to  permit  the 
student  to  so  adapt  it  by  the  election  of  his  work  with 
the  advice  and  approval  of  his  instructors. 

It  will  be  no  purpose  of  the  elective  system  to  make 
specialists  of  the  undergraduate  student,  and  any  ten- 
dency in  this  direction  may  be  readily  avoided.  It  is 
unfortunate  that  the  term  “elective”  should  have  been 
used  in  such  a restricted  sense  by  some  writers  a s apply- 
ing only  to  a system  where  the  student  is  allowed  ab- 
solute freedom  of  choice  as  between  major  branches. 
All  of  the  advantages  of  election  may  be  secured  in  full 
measure  by  requiring  a specified  minimum  of  work  in 
each  branch,  as  in  anatomy,  physiology,  medicine,  sur- 
gery, obstetrics,  and  the  like,  but  permitting  choice  as  to 
topics,  methods  of  study  and  of  teachers.  Such  a de- 
mand together  with  the  requirement  of  the  approval 
of  a dean  or  other  officer  of  the  registration  card,  and 
the  subjection  of  the  student  to  a thorough  practical 
examination  in  each  of  the  major  subjects,  previous  to 
graduation,  affords  a perfect  safeguard  against  this 
abuse.  Moreover,  the  good  sense  and  judgment  of  the 
student  himself,  which  teachers  are  prone  to  under- 
estimate, are,  in  themselves,  a sufficient  safeguard. 

I have  elsewhere  discussed  the  merits  of  the  elective 
system  as  applied  to  medicine,1  and  the  limits  of  this 
address  preclude  a fuller  presentation  of  this  important 
topic  at  this  time.  It  will  suffice  to  say  that  in  the  med- 
ical schools  where  it  has  been  adopted  on  the  most  lib- 
eral lines,  it  has  proven  eminently  satisfactory  and  has 
been  demonstrated  to  be  quite  as  decided  an  advance 
in  the  medical  as  in  other  departments  of  education. 

THE  CONTINUOUS  SESSION. 

The  continuous  session,  in  one  form  or  another,  will 
be  a conspicuous  feature  of  the  university  medical 
school;  that  is  to  say,  the  school  will  be  in  session,  with 


1.  Bulletin  of  the  Am.  Acad,  of  Med..  July.  1900. 


perhaps  slight  intermission  throughout  the  year  in 
northern  climates  where  work  in  the  summer  months 
is  feasible.  A board  of  trustees  composed  of  business 
men  will  be  little  likely  to  allow  an  expensive  plant 
to  lie  idle  three  or  four  months  of  the  year,  any  more 
than  they  would  close  a manufacturing  plant,  represent- 
ing an  investment  of  several  millions  of  dollars,  for  a 
like  period.  And  this  does  not  mean  that  only  special 
or  supplemental  courses  for  teachers,  physicians  or  stu- 
dents will  be  offered  during  vacation  period,  but  that 
full  work  will  be  done  throughout  the  year,  exactly  the 
same  during  the  summer  months  as  at  other  periods. 
Such  a plan  is  scarcely  feasible  except  under  the  elective 
system,  for  reasons  sufficiently  obvious.  The  continu- 
ous session  is  especially  advantageous  to  the  self-sup- 
porting student,  who  may  often  find  it  more  convenient 
to  devote  the  winter  months  to  some  bread-winning  oc- 
cupation. It  is,  moreover,  of  assistance  in  subdividing 
the  classes,  especially  for  clinical  work,  which  can  only 
be  done  satisfactorily  in  small  groups.  Many  diseases, 
too,  are  to  be  seen  and  studied  in  the  summer  which  are 
peculiar  to  that  season.  The  continuous  session  will 
enable  the  ambitious,  progressive  student  to  shorten 
the  period  between  his  matriculation  and  graduation, 
and  this  ought  to  be  made  possible.  It  is  true  that  this 
is  in  contravention  of  the  present  medical  practice  acts 
and  of  the  rulings  of  the  several  state  boards  of  medical 
examiners — rulings  which  seemed  necessary  to  correct 
a serious  evil  at  the  time  they  were  passed,  but  there  is 
no  logical  defense  for  the  present  chain  and  halter 
method  of  hitching  students  together  and  compelling  all 
to  go  at  an  unvarying  pace.  A certain  minimum 
amount  of  accomplishment  should  be  demanded,  but 
while. one  student  might  require  five  full  years  to  com- 
plete such  a course,  another  may  do  it  equally  well  in 
three,  and  he  should  be  permitted  to  do  so.  Alexander 
Hamilton  completed  a law  course,  ordinarily  requiring 
three  vears,  in  four  months — an  extreme  exception,  to 
be  sure,  but  illustrative  of  the  great  difference  in  power 
of  accomplishment  between  individuals. 

The  same  laboratory  methods  which  have  been  so  suc- 
cessfully applied  to  the  fundamental  branches  must  be 
utilized  in  the  teaching  of  the  clinical  branches,  and 
this  means  that  the  medical  school  must  have  hospitals 


23 


— not  necessarily  large — under  its  absolute  control  and 
available  for  research  work  in  the  clinical  branches  by 
all  modern  methods.  It  means,  too,  that  some  of  the 
clinical  teachers  will  be  wholly  engaged  in  teaching  and 
research  work  to'the  exclusion  of  practice,  and  an  ade- 
quate corps  of  trained  assistants,  both  in  laboratory  and 
clinical  lines.  The  clinical  faculty  will,  therefore, 
comprise  two  classes — those  who  are  exclusively  devoted 
to  teaching,  research  work  and  hospital  practice,  and 
who  are  adequately  compensated  therefor,  and  those  who 
are  in  active  practice — both  hospital  and  private,  but 
who  devote  a portion  of  their  time  to  teaching  and  in- 
vestigation. 

THE  EXTRAMURAL  CLINIC. 

While  the  university  must  have  research  hospitals 
under  its  own  control,  the  amount  of  clinical  material 
which  is  required  for  the  large  number  of  students  is 
so  enormous,  and  the  expense  of  maintaining  large  hos- 
pitals so  stupendous,  that  it  seems  unlikely  that  the 
millions  of  money  which  such  a plant  would  require  will 
be  within  the  control  of  the  university  in  the  near  fu- 
ture. But  even  with  unlimited  means,  it  would  be  poor 
business  policy  to  neglect  the  large  amount  of  clinical 
material  already  available  in  existing  hospitals,  but 
unutilized  for  teaching  purposes,  and  especially  would 
this  be  unwise  in  view  of  the  fact  that  the  use  of  these 
patients  for  teaching  purposes  is  certain  to  be  of  great 
advantage  to  the  patients  themselves.  No  patients  are 
so  exhaustively  examined,  so  carefully  studied  and  so 
well  treated  as  those  who  are  the  subjects  of  clinical 
teaching. 

In  almost  every  large  city  are  hospitals  in  which  the 
members  of  the  attending  staff  are  anxious  to  teach ; and 
students  are  sorely  in  need  of  clinical  material.  All  of 
this  difficulty  may  be  adjusted  by  a system  of  extramu- 
ral clinics.  Needless  to  say  that  the  members  of  the 
several  staffs  who  are  appointed  to  extramural  positions 
should  be  selected  with  due  reference  to  their  capacity 
as  teachers  and  investigators,  and  never  should  one  be 
given  such  an  appointment  merely  because  he  can  com- 
mand a large  amount  of  clinical  material.  By  judicious 
effort  in  many  cases  the  appointment  of  competent  men 
can  be  secured  to  hospital  staffs  to  the  betterment  of  the 


24 


clinic  and  the  advantage  of  the  patients,  as  well  as  for 
the  extension  of  the  extramnral  work.  The  removal  of 
these  hospitals  by  some  distance  from  the  college  is  not 
an  insurmountable  objection,  for  students  will  cheer- 
fully go  a considerable  distance  to  receive  such  opportu- 
nities if  the  courses  are  only  so  arranged  that  the  time 
spent  in  going  and  coming  be  not  too  great  in  propor- 
tion to  the  hours  occupied  by  the  course.  It  is  usually 
best  to  arrange  these  courses  so  they  will  occupy  a half- 
day. In  the  very  large  cities  the  establishment  of  two 
or  three  clinical  centers,  where  students  may  remain 
in  residence  for  the  whole  or  part  of  the  year,  will  en- 
able all  of  the  hospitals  to  be  easily  reached.  Extra- 
mural teaching  is  only  possible  under  the  elective  sys- 
tem, where  credit  is  given  for  the  work  on  the  course 
for  the  degree,  for  the  student’s  time  is  too  fully  occu- 
pied to  permit  of  his  giving  much  time  to  work  which 
carries  no  credit.  The  control  of  very  large  charity  hos- 
pitals by  political  appointment  should  be  no  discourage- 
ment, for  by  the  combined  and  persistent  efforts  of  the 
faculty,  aided  by  the  influential  men  of  the  board  of 
trustees,  even  these  obtuse  politicians  can  sooner  or  later 
be  convinced  of  the  enormous  advantage  to  the  institu- 
tion and  its  inmates  of  this  kind  of  service. 

The  necessity  for  great  care  in  the  courteous  and 
careful  handling  of  patients  needs  to  be  strongly  empha- 
sized, for  nothing  will  be  more  certain  to  prejudice  the 
public  against  clinical  work  of  this  kind  than  a harsh, 
discourteous  manner  on  the  part  of  the  clinician,  the 
undue  and  unnecessary  exposure  of  the  body  sometimes 
resorted  to,  or  the  granting  of  too  great  liberty  to  the 
thoughtless  student.  An  undergraduate  should  rarely 
be  allowed  to  examine  a patient  except  in  the  presence 
of  an  instructor.  Properly  conducted,  extramural  clin- 
ical teaching  is  of  advantage  to  the  patient,  the  student, 
the  attending  physician,  the  hospital;  indeed,  to  all 
concerned,  and  it  offers  a ready  and  practical  solution  of 
a serious  difficulty  which  just  now  presents  itself  to  the 
medical  school. 

THE  MIGRATION  OF  STUDENTS. 

The  migration  of  students  from  one  school  to  an- 
other, such  as  is  common  in  the  German  universities,  is 
a plan  which  ought  to  be  encouraged.  Such  a custom 


25 


enlarges  the  student's  latitude  of  election,  broadens  his 
mental  outlook,  and  the  constant  interchange  of  stu- 
dents strengthens  and  stimulates  the  several  colleges 
and  the  individual  teachers. 

PRACTICAL  EXAMINATIONS. 

The  question  of  thorough,  practical  examinations  as 
the  final  test  of  the  student's  ability  to  enter  safely  on 
the  practice  of  his  profession,  has  been  much  neglected 
in  America.  It  is  a matter  of  great  importance  and 
must  be  satisfactorily  solved  by  the  university  medical 
school,  but  time  does  not  permit  a fuller  discussion  of 
the  matter  in  this  address. 

THE  NEED  OF  ENDOWMENT. 

The  expense  of  carrying  out  the  scheme  which  I have 
briefly  outlined  for  a modern  medical  school  is  enor- 
mous. With  the  largest  classes,  and  even  prohibitory 
fees,  the  income  from  tuition  must  fall  far,  far  short 
of  meeting  that  cost.  In  a word,  the  cost  of  a modern 
medical  education  has  grown  to  be  greatly  in  excess 
of  the  student's  ability  to  pay  for  it.  State  aid  or  pri- 
vate endowment  must  be  had  if  these  plans  are  to  be 
realized.  With  our  present  outlook  private  benefi- 
cence holds  out  much  the  larger  promise,  and  in  the 
hope  of  such  assistance  there  is  every  reason  to  feel 
the  greatest  encouragement.  The  recent  gifts  to  medi- 
cal institutions  and  for  the  promotion  of  medical  re- 
search on  a princely  scale,  furnish  conclusive  evidence 
of  the  fact  that  men  of  Affairs  and  of  large  capital, 
whose  chief  desire  is  to  find  a use  for  their  means 
which  shall  be  of  the  largest  service  to  the  world,  have 
come  to  realize  that,  in  these  medical  channels,  large 
gifts  are  more  likely  to  yield  a certain,  speedy  and 
bountiful  return  in  good  to  the  world  than  in  almost 
any  other.  And  so,  in  conclusion,  let  me  assure  you 
that  the  outlook  is  most  hopeful.  The  modern  univer- 
sity school  is  already  in  existence  in  three  or  four  cities, 
and  while  it  has  not  yet  come  to  its  full  glory  and  use- 
fulness, we  may  rest  assured  that  the  signs  are  most 
encouraging,  and  that  in  the  near  future  we  shall  have 
in  operation  in  America  medical  schools  in  advance  of 
any  which  the  world  has  yet  seen. 


UNIVERSITY  OF  ILLINOI9-URBANA 


